The relationship between triggers, pathological changes, disease characteristics, symptoms and quality of life (QoL) in chronic obstructive pulmonary disease (COPD). The relationship between triggers, pathological changes, disease characteristics, symptoms and quality of life (QoL) in chronic obstructive pulmonary disease (COPD). Inhaled environmental noxious stimuli, particularly cigarette smoke, trigger a cycle of pulmonary parenchymal and airway damage, mucociliary dysfunction and airway and systemic inflammation. This cycle is also driven by exacerbations. Breathlessness is one of the cardinal symptoms of COPD and has a negative impact on QoL, in particular by reducing patients’ exercise tolerance and ability to carry out daily activities. C. J. Jolley, and J. Moxham Eur Respir Rev 2009;18:66-79 ©2009 by European Respiratory Society